Boston University School of Medicine
Timing of first whole blood transfusion and survival after major hemorrhage in trauma patients
Key points Is the timing of the first whole blood transfusion associated with improved early and late survival among adult trauma patients presenting with major bleeding? Findings In this cohort study of 1394 patients who had severe traumatic hemorrhage requiring massive transfusion, shorter time to first whole blood transfusion was associated with improved 24-hour and 30-day survival, with a benefit of Survival observed as early as 1 hour after arrival to the ED. Meaning These findings suggest the importance of timing of the first whole blood transfusion when given as an adjunct to a massive transfusion protocol. |
Importance
Civilian trauma centers have revived interest in whole blood (WB) resuscitation for patients with life-threatening hemorrhages. However, there is still insufficient evidence that the timing of whole blood (WB) transfusion when given as an adjunct to a massive transfusion protocol (MTP) is associated with a difference in patient survival outcome.
Aim
To evaluate whether earlier timing of first whole blood (WB) transfusion is associated with improved 24-hour and 30-day survival for adult trauma patients presenting with major bleeding.
Design, environment and participants
This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database from January 1, 2019 to December 31, 2020, for adult patients presenting to civilian trauma centers. level 1 and 2 for adults in the US and Canada with systolic blood pressure less than 90 mm Hg, with shock index greater than 1 and requiring massive transfusion protocol (MTP) who received a whole blood transfusion transfusion (WB) within the first 24 hours of arrival to the emergency department (ED).
Patients with burns, prehospital cardiac arrest, deaths within the first hour of arrival at the emergency department, and transfers between centers were excluded. Data was analyzed from January 3 to October 2, 2023.
Exposure
Patients who received whole blood (WB) transfusion as an adjunct to MTP (above) compared to patients who had not yet received WB as part of MTP (later) at any given time within 24 hours of arrival on the service of emergencies.
Main results and measures
The primary outcomes were survival at 24 hours and 30 days.
Results
A total of 1,394 patients met inclusion criteria (1,155 men [83%]; median age, 39 years [IQR, 25-51 years]). The study cohort included patients with deep injuries (median injury severity score, 27 [IQR, 17-35]).
A survival curve demonstrated a difference in survival within the first hour from ED presentation and whole blood (WB) transfusion.
Whole blood transfusion as an adjunct to MTP given earlier compared with later at each time point was associated with better 24-hour survival (adjusted hazard ratio, 0.40; 95% CI, 0.22-0. .73; P==0.003).
Similarly, the survival benefit of early whole blood (WB) transfusion remained present at 30 days (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.45; P < 0.001).
Conclusions and relevance
In this cohort study, receiving a prior whole blood (WB) transfusion at any time within the first 24 hours of ED arrival was associated with improved survival in patients presenting with major bleeding. The survival benefit was observed shortly after transfusion.
The findings of this study are clinically important as earlier timing of whole blood (WB) transfusion administration may offer a survival advantage in patients with active bleeding requiring MTP.
Comments
Significant bleeding due to traumatic injuries is the number one cause of preventable deaths in the US, with most deaths occurring within six hours. Emerging evidence suggests that transfusion of whole blood (blood that is not separated into parts) is associated with a survival benefit compared to the traditional use of transfusion of blood components (red blood cells, plasma, and platelets) in these patients.
A new study by researchers at Boston University Chobanian & Avedisian School of Medicine shows that the sooner a whole blood transfusion is received for severe traumatic bleeding, the better the chances of survival. However, if this transfusion was delayed by just 14 minutes after arriving at the hospital, the survival benefit was significantly reduced.
"These findings may lead physicians and hospital systems to consider whole blood as a standard emergency transfusion product incorporated into the massive transfusion protocol," says corresponding author Crisanto Torres, MD, MPH, assistant professor of surgery at the school. "There may be a similar benefit in using whole blood transfusion at the site of injury or during transport."
Researchers analyzed 1,394 patients nationwide who presented to the emergency department with severe traumatic bleeding that required massive transfusions, including whole blood, due to their traumatic injuries.
They evaluated whether early receipt of whole blood transfusions was associated with improved 24-hour and 30-day survival compared with late whole blood transfusions in trauma patients with severe bleeding receiving massive blood transfusions with component-based therapy. .
Patients who received a whole blood transfusion before arrival to the emergency department had better survival rates.
“Our study indicates a target time goal for administration of whole blood within 14 minutes of arrival at the hospital. "There is a decrease in the probability of survival for each minute of delay in whole blood transfusion, but the most pronounced reduction in the probability of survival was observed after 14 minutes," added Torres, who is also a trauma surgeon at the Boston Medical Center.
